The Slippery Slope of Declining Low-Value Medical Services

While hundreds of “low-value” medical services are driving up health care costs, eliminating these services altogether could hurt some patients by denying them access to potentially appropriate care.

Procedures such as prostate cancer screening for men over 75, MRIs for low back pain, X-rays prior to low-risk surgeries are examples of services paid for by consumers and insurance companies that may be unnecessary, or worse, harmful. As a result, many providers and policymakers want to eliminate low-value medical care. ¹ However, because low-value services are not the same as no-value services (e.g., prescribing antibiotics for a viral infection), some patients may still benefit from these services.

AARP Public Policy Institute researchers contend that efforts to reduce unnecessary care must ensure appropriate care is not withheld from patients.

 

What Are Low-Value Services?

Low-value services are medical tests or procedures with little clinical benefit for which the potential for patient harm exceeds possible health benefits. ³ The American Board of Internal Medicine Foundation created the Choosing Wisely campaign to catalog potentially unnecessary medical services and promote conversations between patients and providers about these services. ⁴

 

The Research

Researchers in the AARP Public Policy Institute wanted to know if the use of certain low-value services declined among adults 50 years old and older between 2009 and 2014, which straddles the launch of the Choosing Wisely campaign. Nine of the 16 services were included on Choosing Wisely.

We analyzed administrative claims data from the OptumLabs® Data Warehouse, a comprehensive, longitudinal, real-world data asset with de-identified lives across claims and clinical information.

Our results showed rates of low-value service use dropped among older adults for all but one of the services studied. ² However, our study cannot distinguish between cases of wasteful and appropriate service use. Because of this, our research prompted several questions:

For which patients does the benefit of a service outweigh the potential harm? While a particular service may be considered low-value to most patients, the same service may be a good option for certain patients.

Why are some low-value services not included on Choosing Wisely lists? Over our six-year study period, the use of renal artery stenting dropped by approximately 75%. A 2009 study showing that renal artery stenting did not provide worthwhile clinical benefit over medical therapy could have led to this decrease. ³  Is renal artery stenting another low-value service candidate?

What is an acceptable utilization rate for each service? While clinicians can probably agree that imaging for every patient presenting with a headache is unnecessary and wasteful, are the head imaging rates of 19-29% in our study on target? Too high? Too low?

 

A Complex Issue Needs Nuanced Solutions

Health care services of little potential value are widely overused. At the same time, these services may be crucial for some patients. Moving forward, before efforts are made to eliminate low-value services from the health care system it will be necessary to 1) distinguish between low-value and no-value medical care and 2) identify patient groups for whom the benefits of low-value services may outweigh the harms.

In the meantime, Choosing Wisely recommends patients ask their provider these 5 questions before undergoing any test or procedure.

 

References

1. Multi-Stakeholder Task Force Identifies "Top Five" Low-Value Services For Purchaser Action [press release]. V-BID Health2017.
2. Carter EA, Morin PE, Lind KD. Costs and Trends in Utilization of Low-value Services Among Older Adults With Commercial Insurance or Medicare Advantage. Med Care. 2017;55(11):931-939.
3. Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361(20):1953-1962.